SALT LAKE CITY - Utah is one of the last states to take a position on Medicaid expansion, and it hasn't been for lack of trying.
State leaders have been putting their heads together for three years to come up with a plan that will help to insure more than 95,000 Utahns, including those who fall in the coverage gap - ineligible for Medicaid benefits and earning too little to qualify for coverage through the federal marketplace.
Various iterations of plans to expand access to health care, including Healthy Utah designed and pitched late last year by Gov. Gary Herbert, have not gained favor in the state's Republican-led House of Representatives or have faced other stumbling blocks in the process.
And for a relatively complicated topic, it seems it might be difficult to get everyone on the same page for the latest plan, UtahAccess+.
"It all comes down to politics," said Leavitt Partners' senior director of state intelligence Laura Summers. "There are positives and negatives for the Legislature to consider ... but a lot of this boils down to politics and whether they are willing to take it on."
It's a pricey compromise, including a bet on the federal government to come through with hundreds of millions year after year to match state dollars going toward health care coverage for tens of thousands of struggling Utahns, most of whom work at least part- time jobs.
The latest plan - being called UtahAccess+ by the governor- appointed group of six who rolled it out two weeks ago - would make beneficiaries partners in the plan, giving them an opportunity to collect a subsidy to pay for a private insurance plan.
People on the plan would also have to pay low-cost monthly premiums and copays, as certain caps on prices are required by the federal government.
UtahAccess+ would also, however, require medical providers to kick in a portion of the cost to implement it, an idea that seems to already be ruffling feathers throughout the medical industry. The Republican caucus in the Utah House doesn't seem to be completely on board.
It is unknown whether the Legislature, which has financial authority on the matter, will even vote on UtahAccess+, but lawmakers heard four hours of public testimony Tuesday, mostly from concerned providers, urging them to reconsider.
Utah's Medicaid Director Michael Hales agrees that some of those providers might be misunderstanding what has been proposed.
"Every experience is going to be different," Hales said Thursday. "Some will be false worry, but some are legitimate concerns."
Some providers have said they have too many Medicaid patients, which net them smaller reimbursement rates for the same services provided to commercial-insurance payers.
"We're paying lower than Medicare and definitely commercial in almost every case," Hales said, adding that the state reimburses about half what commercial plans pay to providers.
But those rules wouldn't apply under the new proposal for Utah's Medicaid expansion, he said.
"One common misunderstanding is that the Medicaid program they've experienced to date is different than what they would likely experience with the Medicaid expansion or the coverage gap solution population," Hales said.
Under the proposed UtahAccess+ plan, newly covered individuals would be covered under commercial reimbursement rates, as they will select and enroll in locally offered private plans, he said. The method is similar to Utah's Avenue H, which is already providing a local marketplace of insurance plans to small-business employees across the state.
Except for the medically frail population who would be put on traditional Medicaid plans, the vast majority of newly insured Utahns "wouldn't be distinguishable" from people who already have commercial plans, Hales said.
"We do feel like most of the providers offering services to Medicaid clients have been pushed to the brink of their charitable goodwill," he added. "It would be unfair to add another 100,000 to the safety-net system and hope that providers will still be able to provide services and make it financially."
Because at least some providers stand to gain revenues from a greater number of insured patients, they're being asked to pay into the program. Lawmakers have said having them involved increases the sustainability and viability of expanding benefits to more Utahns.
The formula to determine how much each provider in Utah will pay in fees was determined based on what was paid out in one given year (2014). The metrics will likely fluctuate, depending on revenues each year, but they run the gamut of medical providers, including doctors and nurses, psychologists and hospice workers, chiropractors and podiatrists, among others.
Not all providers who are being asked to foot a portion of the bill for the potential health care expansion program, however, will see a benefit from taking part in the program.
"Some would win, some would lose, even within different provider types," Hales said.
The fee schedule, he said, is aimed to be "as fair as possible at the big-picture level, but once you drill down to the different individual provider groups and the individual practices, there are still winners and losers, even within those practices."
Pediatricians only see children, who aren't a part of the proposed expansion population; and there are doctors who aren't accepting any new patients or who aren't members of certain insurance provider networks, who likely won't see revenue increases from an increased population of insured individuals.
But, Hales said, in order for the state to collect federal monies and get the full federal match rate to pay for the expanded program, Utah would have to institute a broad-based tax, uniformly assessing all providers, none of whom can be held harmless. Everyone in the "medical provider category" has to pay or Utah can't collect the federal portion of taxes already going to Washington, D.C., he said.
Hospitals, which have offered to cover as much as $25 million of what will be more than $50 million proposed state costs in 2021, stand to benefit the most.
"By and large, hospitals have to treat everyone who shows up in their emergency department, and that has historically built up a large amount of what is called uncompensated care," Hales said.
Much of that uncompensated care provided to previously uninsured patients would be picked up by insurance companies presumably covering the currently uninsured population if expansion were implemented in Utah.
As it stands, those costs are passed on to insured individuals and families in Utah, as all premiums "carry a certain load of the uncompensated care offered at hospitals," Hales said.
"Hospitals can't lose money and stay in business," he said.
And as evidenced in the recent past, large uninsured populations tend to drive up the cost of commercial plans to the point that some employers might ultimately drop those expensive plans, which could then increase the uninsured population.
But the idea of health care reform, as expressed in the more than 2,000-page Affordable Care Act of 2010, is that with a presumably healthier population and fewer uninsured people heading to costly, nonemergent emergency room care, the general public might see more affordable options for health care.
"The best you could hope for is a more sustainable rate of growth in insurance premiums, rather than the large growth we've seen in years past," Hales said.
Access to health care, he added, can also help people with mental or behavioral health issues (who make up a large portion of the uninsured population) keep up with necessary appointments and medications, "become stabilized and be more functional in society."
Summers said benefits to the general public and people who already have insurance might be tangential, but a substantial amount of taxpayer dollars would also be coming back into the state's own economy, potentially increasing the workforce in health care- related and other fields.
Approximately $680 million in tax dollars from Utah goes to the federal government every year for health care - Medicaid and Medicare programs, as well as others.
As an incentive for states to expand Medicaid, the Affordable Care Act proposed that up until 2017, the federal government would pay 100 percent of the expansion cost. That number drops to 95 percent in 2017 and declines to 90 percent by 2020.
By 2021, states will pay the remaining 10 percent for their own Medicaid expansion costs, which is what has some lawmakers worried about sustainability in rolling out a plan.
The House GOP plans to take a straw poll during a closed-door caucus Tuesday. If not enough support exists, Summers said, it could be back to the drawing board, or the state could just continue with a large population of uninsured residents.
In her work tracking nationwide movement on health care reform, Summers said states that don't reach an agreement and decide not to expand benefits typically haven't continued discussion on the matter.
"Having debated the issue for so long, there definitely is the possibility that people are getting fatigued," she said, adding that other states have found that bringing up the same topic over and over really hasn't resulted in anything positive.
"Unless the governor takes executive action, which isn't an option in Utah, ... it takes a change in the Legislature or a change on the executive level," Summers said, regarding action in other states.
The nonprofit Kaiser Family Foundation reports that 31 states and the District of Columbia have expanded Medicaid, with at least five having developed alternate plans for expansion. Others, including Utah, are working on plans or waivers to present to the federal government for final approval.
Nineteen states have not expanded services, however. And another health care advocacy organization, Families USA, has named Utah "a state to watch" on the matter.
UtahAccess+, which is similar to Herbert's Healthy Utah, is akin to what Arkansas is doing, except for the cost- sharing option. And other states have implemented programs that offer plans from the private marketplace and charge enrollees a premium, as Utah's model proposes.
"I've never seen a provider tax like Utah is proposing," Summers said.
But as it gets closer to 2017, when states have to pay more into the program, she said, "we may see more states look to the Utah model or other alternatives to see how they can sustain these costs over time."
There are states that have talked about a hospital assessment or other taxes on durable goods, but few have implemented anything, according to Kaiser.
"It is a lot to grapple with," Summers said.
States slowly caught on the first time Medicaid was an option in 1965, she said.
"It was over a long period by the time every state moved into it," Summers said. "We may see the same with Medicaid expansion."
Summers said she expects the nationwide conversation to continue, "unless there's major changes to the Affordable Care Act or something that gets rid of it altogether."
Hales said Utah officials have hashed out the details of different scenarios and came back to the basic tenets of Herbert's Healthy Utah plan because it works.
"We thought he had a good proposal on the table," he said. "We're hopeful there will be a solution."
Email: wleonard@deseretnews.com
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